Understanding and Respecting Professional Boundaries, Part IV

Even most solo practitioners need help in serving their patients and performing the ever-increasing administrative tasks necessary to provide top-notch services. The larger the practice, the more help is needed, whether or not your practice is computerized. This being the case, you are going to have to hire people to carry out the administrative and adjunctive health care services you may want to incorporate into your practice. This presents a two-pronged question: who do you hire relative to employment law and professional boundaries? This and the next article will deal with the area of professional boundaries relative to hiring employees, as well as doctor/doctor, doctor/patient and doctor/employee relations.

Ever-Increasing Numbers of Employees Are Filing Lawsuits Against Doctors of Chiropractic

As sad as it is, not everyone permanently likes or loves one another. Very often expectations are not lived up to, people get into personality hassles, etc., causing fractures in relationships, many of which cause employees and doctor associates to file lawsuits and/or complaints with the practitioner's board of examiners.

Employment discrimination, disagreements and/or violation of sexual boundaries are very serious matters. Whether or not an allegation is true, it has to be investigated by the practitioner's board of examiners and very often other governmental agencies. The process of defending oneself is expensive and to a large degree is avoidable when the practitioner has knowledge and applies wisdom in risk management principles. The following are some risk management principles you might want to consider incorporating along with the others we discussed in previous articles. As you contemplate them, we suggest you update yourself on the current rules and regulations of your particular board of examiners and seek the services of an attorney who is skilled in labor (and chiropractic) law.

You Can Never Be Too Careful in Your Hiring Methods

Everyone has both a child and an adult nature. Very often doctors hire people without doing proper investigation, or solely on the adult impressions the prospective employee transmits during the initial interview. Too often, a prospective employee's skills are allowed to take precedent over the soundness and stability of their personality. You should always be on the lookout for possible future employees, which involves a continual evaluation process that better prepares you to decide what you need and want in an employee before the need arises.
You should never hire a person just because you have a position to fill. Very often practitioners make the mistake of hiring a relative, patient, former patient/employee or significant other, thinking that they know the individual. As good as doing so may at first glance seem, you should also keep in mind that the more an employee knows about you, the more ammunition they have to use against you if you fail to live up to their expectations.

From a risk management perspective, you usually are far better off hiring people with whom you have little or no personal history. Time and time again, employees who know personal information about their employer (information that would not necessarily be illegal or unethical) turn that knowledge into accusations. This situation can be avoided if the people hired know nothing of their employer's personal life and little of their professional life.

Some practitioners do violate laws, rules and/or regulations. By law, many states require that if you know of such a violation, you must turn that practitioner over to their board of examiners. For uncountable reasons, non-licensed relatives, former significant others, former employees and/or patients may decide to get you. If they know of things in your personal and/or professional life that they perceive as illegal or which would make your life difficult, they have ammunition to use against you.

The intelligent practitioner never gets sexually involved with an employee, patient, former patient or colleague. In addition to being illegal, it is also foolhardy. Sex should be limited to the person to whom you are legally married. Allowing hormones and emotions to be in control rather than human dignity, personal respect and discipline has needlessly harmed countless professional and personal lives.

Keep your business and professional life to yourself. This holds true for everything, including the money you earn. No employee should ever be allowed to know your income or what you do with your finances. Likewise, there is no place for a personal relationship with anyone connected to your present or past practice. Don't be dumb enough to think that you can have personal relationships with staff, patients or contract employees/practitioners and not end up paying a costly price. Governmental privacy acts are good, but the downside of protecting privacy is that we don't see how many other practitioners' careers have been destroyed because they violated professional boundaries and equal employees laws.

Be Careful Not to Rule or Dominate Patients

When people come to you for help, we are called to practice due diligence. We attempt to discover as much as we can about a patient's past medical history, perform examinations and appropriate diagnostic tests, make a diagnosis, develop a treatment plan, and offer the best care we believe appropriate to their situation. But it is wrong to try to sell or control patients. We need to treat others as we would want ourselves or our loved ones to be treated. What might be popular or the latest thing being taught by practice management coaches may not in fact be ethical or honorable. Just because others use a certain method to care for or sell patients on receiving care does not make it legal or ethical.

Compliance Issues

To varying degrees, everyone has some areas in which they are unteachable. We have to accept that and do what we can to educate patients regarding their health issues while never using fear or other procedures to get patients to accept and follow through with our recommendations.

Sometimes, no matter how hard you try to be honest and communicate with patients, they aren't going to understand you or accept your recommendations. When that happens, accept it and let them go about their business. Once in a while, a patient shouldn't be at our clinic or isn't open to what we feel is best for them. If that happens, accept it and allow them to do what they want to do outside of your realm of life.

Just because a patient doesn't follow your recommendations doesn't mean that you have failed or that they're stupid. People are people; not everyone is where we're at, and that's OK. Focus on the positive, not the negative. Don't stew over the negative. See it not as a problem but as an opportunity to learn and move on to better communication and positive relationships.

Sometimes patients lack the mental ability to understand what we do or suggest, and we have to accept that. If you've done all you can do in ethical and reasonable ways, you've done your best, and it's up to the patient to make whatever decision they want to make. Sometimes along with their physical problems, patients bring emotional "baggage" that has relational causes to their physical problems and prevents them from comprehending what you've said or hinders their getting well. When that occurs, accept it and refer them to someone who may be better equipped to handle their issues.

If you know the conditions and personalities you're best suited to relate to, you will attract those types of patient, and both you and the patient will be happy. If you try to be everything to everybody, you will open the door to attracting patients on whom you're going to expend all kinds of wasted energy and services. In the quest for success, practitioners are often too aggressive procuring patients and attempting to take care of anyone and anything which gets them into trouble. If a patient demonstrates a repeated pattern of low compliance, state it in your records and discuss it with them. If they refuse to change, release them with mercy and grace via referral to another practitioner. If a patient refuses your recommendations, state so in your records.

Some older people may appear to be mentally sound, but at times they may not fully comprehend what you recommend, creating the possibility of misunderstanding. Thus, it is imperative that we do all we can to ensure that older people understand us. If necessary, see to it that another adult is in attendance during their visit and that appropriate liability forms are signed. Again, we cannot overemphasize the importance of using patient acknowledgment and waiver forms discussed in previous articles.

If you have patients who are manipulative or controlling, they should be referred to another practitioner.

If you have patients who you or a member of your staff suspect are emotionally high-maintenance type people, or are attaching themselves to you emotionally, they need to be referred to another practitioner.

When You Try to Control Others, Your Life Becomes Unmanageable

All practitioners have been educated to make decisions. From that educational perspective, we can be tempted to be authoritative and controlling. This is a weakness that needs to be dealt with and can be if you make up your mind to change for the better. We are not superior to anyone. We are not authorized to control or emotionally manipulate people. With that in mind, let's look at some common characteristics of manipulative and controlling personalities. We do so with the hope that if you are crossing the line or stepping outside of the usual doctor/patient, doctor/staff boundaries, you will recognize it and take the appropriate steps needed to correct yourself.

1. Relate to people from a horizontal, not vertical, perspective. You are not God, you are not the ultimate authority, and people have the right to be treated fairly and with human dignity.

    

2. Your education and license puts you in a power position, but it does not grant you the right to dominate or control people. Certainly, we usually know what might be best for most of the people who come to us, but we violate their rights when we attempt to impose our opinions upon them or use pressure techniques. A good physician is a servant, not a controller.

We all have opinions, some right and some wrong. Immature and unsure people are self-serving and commonly want their opinions known and followed. Mature people recognize that at times we all are tempted to see things the way we would like them to be rather than as they are. It doesn't matter so much that we agree with everyone, but rather that we accept their opinion, not try to impose our opinions or lifestyle on others. Everything has two sides. It's possible that we may not always see the entire picture or where other people are coming from.

Even those who don't agree with us can profit from their contact with us if we maintain a servant's heart and attitude. It never pays positive dividends to make someone angry, get angry, or try to get even. We are in fact chained slaves to anyone we hate, are angry with, or won't forgive. Hatred, anger and unforgiveness are like acids; they can destroy the vessels that hold them. Plotting revenge allows people who have hurt us to hurt us deeper and continue to control our lives. If there has been a problem in a relationship, do what you can to resolve it and get on with your life.

References

Lalla GT. Fellowship of the Great Physician: Essentials of Risk Management in the Pastoral Setting, Jan. 1993.

Wolfe J. NWCC Homecoming, Professional Boundaries, Feb. 1999.

Wolfe J. NWCC Homecoming, Professional Boundaries, Sept. 1996.

25 steps to avoid boundary violations in employment relationships. Adapted from: Spicer L. 25 steps to navigate the slippery slope of sexual boundaries. Chiropractic Economics May/June 1996.